Provider Demographics
NPI:1992793574
Name:LAURENCE OF OAKLAND
Entity type:Organization
Organization Name:LAURENCE OF OAKLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-718-8252
Mailing Address - Street 1:3161 PUTNAM BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4650
Mailing Address - Country:US
Mailing Address - Phone:510-658-2062
Mailing Address - Fax:510-658-7779
Practice Address - Street 1:3324 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-658-2062
Practice Address - Fax:510-658-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGFC000120Medicaid
CA0233210001Medicare NSC